CRD summary

The review concluded that family therapy was an effective form of psychotherapy for anorexia nervosa, effectiveness of cognitive-behavioural therapy was not conclusive and the superiority of other psychotherapies over conservative management was not established. Limitations in the review, reporting of review processes, uncertain study quality and a small evidence base mean the authors conclusions should be treated with caution.

Authors' objectives

To determine the clinical effectiveness of psychotherapies in the management of anorexia nervosa.

Searching

EMBASE, PubMed and The Cochrane Library were searched up to 2010 for full text articles published in English. Reference lists of relevant articles were checked for additional studies.

Study selection

Controlled trials of female patients with anorexia nervosa as their primary condition that focused on a psychotherapy (recognised for treatment of anorexia nervosa by the National Institute of Clinical Excellence (NICE) were eligible for inclusion. Trials had to report treatment success using at least one validated outcome measure for weight. Studies were required to use a definition of anorexia nervosa concordant with either ICD (International Statistical Classification of Diseases and Related Health Problems) or DSM (Diagnostic and Statistical Manual of Mental Disorders) criteria. Patients needed to have an average age of less than 30 years. Open trials and articles that were more than 25 years old and where no citation was found were excluded.

Most studies focused on two main forms of psychotherapy: family therapy, including separated family therapy and conjoint family therapy; and cognitive-behavioural therapy (CBT). Other psychotherapies included cognitive therapy, interpersonal therapy, cognitive analytical therapy and educational behavioural therapy. Where reported, mean age of patients ranged from 15 to 25 years and mean body mass index (BMI) ranged from 15 to 17kg/m². Various outcome measures were reported. The most frequent measures of weight were BMI, Morgan and Russell scale and Eating Disorders Inventory.

The authors did not state how many reviewers selected studies for inclusion in the review.

Assessment of study quality

The authors did not appear to formally assess the methodological quality of the included studies.

Data extraction

The authors did not state how many reviewers performed the data extraction. Some study details were extracted and a brief narrative summary of the results provided.

Methods of synthesis

A narrative format was used to synthesise data grouped by type of therapy (family therapy, CBT and other psychotherapies).

Results of the review

Twelve studies were included in the review (646 participants, range 24 to 167). Study design was not stated for each study but at least five studies were described as randomised controlled trials. Only one study had a follow-up of more than one year.

Family therapy (five studies): Four studies found significant improvements for psychological therapy on measures of weight. Two RCTs demonstrated significant improvements for psychological therapy compared to controls (no further treatment and treatment as usual). Another RCT and a pilot study only compared two different types of family therapy with each other. One RCT found a significant difference in weight gain in favour of the control arm (dietary advice) compared with two different types of family therapy.

CBT (four studies): One study demonstrated significantly better weight gain and lower failure rate in favour of CBT than controls. Two studies demonstrated no significant between-group differences (patients in all arms gained weight). One study demonstrated significantly greater improvement in the control group (non-specific supportive clinical management) than psychotherapy (CBT or interpersonal therapy), although it was unclear to which outcomes this applied.

Other psychotherapies (three studies): One study found cognitive therapy to be significantly more effective on BMI than dietary counselling; lack of compliance in control group may have influenced this result. Two studies found no significant between-group differences on measures of weight or other outcomes.

Authors' conclusions

Family therapy was an effective form of psychotherapy for anorexia nervosa and it seemed feasible that it could be offered to patients in outpatient care. The effectiveness of CBT was not conclusive. The superiority of other psychotherapies over conservative management was not established.

CRD commentary

The broad review question was supported by clear inclusion criteria in terms of population and treatment. Study design was restricted to controlled studies but the authors did not clearly define this; it appeared that one before-and-after study (with a comparison within the group) was included. Several relevant electronic databases were searched. The search was restricted by language and publication status which raised the possibility of publication and language biases. It was not clear whether appropriate procedures were taken when selecting studies or extracting data to minimise the likelihood of error and bias. It did not appear that the authors formally assessed the quality of the included studies, which limited interpretation of the results.

Incomplete study details were presented (for example duration and intensity of the intervention and intervention content were not reported) and this made it more difficult to determine whether a narrative or meta-analysis would have been the most appropriate form of synthesis. The reported narrative synthesis represented little more than a brief summary; estimates for individual studies and outcomes were not reported and this made it difficult to verify the accuracy of the summary of the results that were provided and establish the clinical importance of the findings. The results were based on a small number of small studies.

Limitations in the review, reporting of review processes, uncertain study quality and a small evidence base mean the authors conclusions should be treated with caution.

Implications of the review for practice and research

Practice: The authors stated that it seems feasible to offer psychological therapy, in particular family therapy, for the treatment of outpatients with anorexia nervosa.

Research: The authors stated that larger blinded population studies were required that compared different types of therapy (such as family therapy and cognitive behavioural therapy) and suggested that future studies concentrate on whether different subtypes of patient responded better to different therapies.

Funding

Not reported.

Bibliographic details

Pittock A, Mair E. Are psychotherapies effective in the treatment of Anorexia Nervosa? A systematic review Journal of Indian Association for Child and Adolescent Mental Health 2010; 6(3): 55-71.

Original Paper URL

http://www.jiacam.org/0603/eatjuly2010.pdf

Indexing Status

Subject indexing assigned by CRD

MeSH

Anorexia Nervosa; Humans; Psychotherapy; Treatment Outcome

AccessionNumber

12012019347

Database entry date

30/11/2012

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.